West Virginia, already plagued by a host of geographic and demographic impediments to effective treatment for mental illness, faces an uphill battle against emerging policies that may further threaten care in the state.

Dead last. That’s the bottom line for the state of West Virginia when it comes to per capita expenditures of state-directed mental health services (SAMHSA, 2001). In the aggregate measurement, it is just as bad. The state ranked 50th in total state-funded expenditures the same year, despite the fact that the state is 37th in total population (US Census, 2000). The state of mental healthcare in West Virginia is so daunting that a mental health provider told NAMI that “this is the worst time for behavioral healthcare [in West Virginia] in the past 25 years.”

It was in 2001 that the state emerged from the Hartley Consent Decree, a 1981 action brought by four residents of Huntington Hospital. The consent decree required federal supervision of West Virginia’s Human Services Agency’s part in providing consumers with constitutionally obligated behavioral healthcare.

In celebrating the exit from the decree, the West Virginia Behavioral Health Providers Association suggested that the pivotal issue of Hartley was “whether or not the state could support these people through alternative funding and support systems like Assertive Community Treatment (ACT) or Medicaid community-focused treatment teams.” If this measure was the central point, then the state has failed miserably. As of 2005, the state lists only two operational teams for the entire state of West Virginia.

West Virginia still approaches behavioral health services without understanding the importance of holistic planning. The state has failed to learn from Hartley, and continues to develop services without adopting a coordinated approach based upon constituent needs and data evaluation. Advocates continue to push for coordinated planning and are advocating legislation to that effect in 2006.

For citizens of West Virginia, the challenges are daunting. The predominantly rural state ranks 48th in per capita income. Citizens with mental illnesses face a potential uphill battle in an environment with low provider availability, a significant community stigma regarding mental illness, a high rate of substance abuse, and a suicide rate that ranks 8th nationally. The road to restoring the state’s mental health system will be adifficult one. Based upon the priorities of current state leadership, the outlook is not good.

Among the serious challenges the state faces are:

Evidence-based practices – evidence-based practices other than ACT fare just as poorly. Measured against states with over 30 counties, practices such as supported housing, supported employment, and integrated dual-diagnosis treatment are scarce. While West Virginia has 55 counties, the most significant penetration achieved by any evidence-based service – supported employment – is six counties. This dispersion of programs suggests there is little access to proven supportive services for people living with mental illness in West Virginia.

Funding – While 90 percent of net patient revenue for community mental health centers in West Virginia is provided by Medicaid, the state legislature in 2005 underfunded Medicaid by $30 million. This resulted in a system loss of over $115 million – including federal contributions through Medicaid – through cuts to provider reimbursements. As a result, mental health consumers were affected by reduced provider availability and reduced services. And the impact of provider rate cuts piled on an estimated reduction of $31 million over three years when the state implemented Medicaid managed care and reduced outlays in support of clinic services, rehabilitation, and targeted case management.

Medications – The state legislature, executive leadership, and Medicaid advisory bodies have rebutted numerous attempts by advocates and provider organizations to overturn restrictive policies that minimize access to needed psychotropic medications. Two pieces of legislation have been introduced in 2006 to address this shortcoming in the state Medicaid program (HB 2046 and HB 2216).

Medicaid – West Virginia recently has stated its intent to make significant modifications to its Medicaid program. The basis of the proposal includes commitment to personal responsibility and greater cost-sharing. For consumers categorically eligible for Medicaid due to disability, early drafts of the plan suggest a broad benefit design with an emphasis on disease management. However, the proposal also seeks consumer-driven care authority which would reward “preferred behaviors” (West Virginia Comprehensive Medicaid Redesign Proposal, May 2005). This poses many risks for people living with mental illness. Consumers might choose to ignore psychiatric symptoms and avoid emergency treatment due to the higher co-pays assigned to emergency department care. Or, recipients might choose less effective medications due to co-pay structures that penalize recipients for using certain branded medications – even when the more expensive medicines are more effective for a given patient.

Housing – Housing currently is monitored on a regional level without the state having direct oversight or planning authority for identification of public housing opportunities. The availability of housing and levels of supported housing vary widely across the state (State response to NAMI survey).

Still, there are positive signs for the state as it goes forward:

Openness – The Bureau for Behavioral Health and Health Facilities does deserve credit for attempts to bring consumers and family members to the table for future decision making and planning. Support is evident for family and peer education from the Bureau. Additionally, the state employs external advocates at both state-operated hospitals to monitor conditions. These examples are promising and must be applied to the entire mental health system if the state is going to reverse its current course.

Diversion – The state’s law enforcement community is directly aware of the consequences of untreated mental illness. In 2005, more than 40 law enforcement representatives attended a summit on developing pre- and post-arrest jail diversion strategies. The meeting is a potential starting point for the state to adopt proven diversion programs; however, there has been little progress made since the initial meeting. This meeting follows on the heels of the state’s Healthy People 2010 report. The report suggests that the state is working to reduce the number of individuals jailed for minor offenses due to psychiatric conditions by 10 percent by 2010. In 2000, 543 people met those criteria. The 2010 report also calls for all West Virginia State Police Academy graduates to have 40 hours of training in mental health issues, far more then the current four hours. A review of the curriculum posted on the Police Academy website suggests these changes have not been incorporated.

Staffing – West Virginia also deserves accolades for taking reasonable first steps to address the state’s chronic shortage of mental health professionals. Using Rural Health Education Partnerships, the state has successfully implemented mental health-specific modules into medical student rotations. This effort is noteworthy in light of state research that shows a majority of West Virginians living with mental illness seek treatment through general practitioners.

There are several important steps West Virginia can take to improve the state’s mental health system:

* West Virginia state leaders must challenge local and county officials to operationalize the lessons learned from a 2005 summit on pre-and post -arrest jail diversion.
* West Virginia must expand implementation of evidence-based practices far beyond its currently sparse distribution across the state.
* West Virginia must adopt a coordinated planning approach based upon constituent needs and data evaluation.
* West Virginia must ensure that any newly crafted Medicaid program does not include pay structures that cause those with mental illnesses to choose not to seek treatment or appropriate medications.